Consumer Guide to Understanding Health Insurance | Mass.gov

How does health insurance work in massachusetts

employment-based coverage

Employers who purchase health insurance must allow all eligible full-time employees to enroll in any health plan offered by the employer. If the employer pays a portion of the premium, the insurance company must ensure that the employer does not pay higher-paid employees more of the premium than other employees. If you get your plan through your employer or union, they will choose the plans they offer and buy the plan from the company. then you can choose the health plan that is best for you from the options offered by your employer or union.

large employer groups

Many employers (those with more than 50 eligible employees) do not purchase insured health plans from insurance companies. instead, they pay for health services from their own self-funded accounts. Although these employers may use insurance companies to process claims and handle other administrative tasks, the insurance companies are just third-party administrators. these are called “self-funded” plans. they are not considered insured plans and federal law exempts them from state law. To find out if state laws apply to your plan, you should ask your employer if your plan is self-funded.

Other large employers buy insured health plans from insurance companies. These plans must comply with all state insurance laws. this includes mandated benefits, eligibility rules, and continuation coverage protections. If the large group purchases the health plan in Massachusetts, the plan must comply with Massachusetts insurance laws. however, a large group can purchase the health plan in another state as part of their national plan and then they would follow the laws of that state.

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small employer groups

Many employers with between 1 and 50 eligible employees include a health plan as part of the employee benefits package. In Massachusetts, sole proprietors are considered small employers and can purchase the same small group health plans available to other small employers.

all small group plans in massachusetts are “guaranteed issue” and “guaranteed renewal”. This means that a company cannot deny your application or refuse to renew your plan based on the amount or cost of services you have used or may use. The company can only refuse to offer or renew a plan for certain reasons, such as fraud or non-payment of premiums.

individual coverage

directly from the carrier or broker

You can buy a health plan directly from an insurance company. You can call a health insurance company directly to enroll in a plan designed for individuals, families, and small groups. many self-employed residents get health coverage this way. You can find a list of companies that offer these plans on the insurance division’s website.

Some companies require you to go through an intermediary. An intermediary is an entity that handles enrollment and premium collection for the company. insurance companies must offer the same health plans to individuals that they offer to small groups. If you’re eligible for Medicare, you can buy a Medicare Supplement plan or Medicare Advantage plan directly from a company that offers that type of plan.

through the connector

If you don’t work for an employer that pays at least 33% of your health plan premium, you can purchase connector coverage. these special plans are called commonwealth election. These plans have the Connector Seal of Approval, which certifies that the plans provide a good value to consumers.

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if your family income is less than 300% of the federal poverty level and you meet certain requirements, you may be able to purchase a connector commonwealth care plan. If your family income is below the federal poverty level, you may be eligible for a plan with no premium. If your family income is between 100% and 300% of the federal poverty level, you may be eligible for a discounted premium.

if you are between the ages of 19 and 26 and are not eligible for subsidized coverage from your job, the connector offers a young adult benefit plan for residents of massachusetts.

qualified student health insurance plans (qship)

if you’re enrolled as a student at a massachusetts college or university, you can purchase a special health plan directly from your school. This qualified student health insurance plan (QSHIP) is designed for students and is only available while you are an enrolled student. Keep in mind that you must have insurance if you are enrolled at least ¾ of the time at a Massachusetts college or university. This is true whether or not you consider yourself a resident of Massachusetts. you are not eligible for commonwealth care if you must purchase a qship or have coverage as a student.

Please note that parents and guardians can keep dependents on their health insurance plans until the dependent turns age 26 or 2 years after the last year the dependent was claimed as a dependent on the federal income tax return. on rent from a parent or guardian, whichever comes first. This dependent care requirement does not apply to self-funded health plans or plans written outside of Massachusetts.

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government health benefit plans

mass health

masshealth is a medicaid program paid for by state and federal taxes for eligible individuals. the division of insurance does not oversee mass health programs. You will need to contact MassHealth for help with your MassHealth health insurance plan.


If you’re over 65 or have a certain type of disability, you may be eligible for Medicare. For more information on Medicare eligibility and benefits, contact us. uu. medicare centers & Medicaid services or your local shine counselor.

other government health plans

The state and federal government provide lower-cost health coverage for certain people through public health programs. This includes Indian Health Services, Peace Corps, CommonHealth, HealthyStart, and other programs.


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